Provider Demographics
NPI:1093464588
Name:LIFE VISION
Entity Type:Organization
Organization Name:LIFE VISION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MITCH
Authorized Official - Middle Name:
Authorized Official - Last Name:PEBLEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:801-513-8933
Mailing Address - Street 1:4138 S 3475 W
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-8457
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:FREEPORT CENTER
Practice Address - Street 2:BUILDING D-11
Practice Address - City:CLEARFIELD
Practice Address - State:UT
Practice Address - Zip Code:84016
Practice Address - Country:US
Practice Address - Phone:801-513-8933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty